Provider Demographics
NPI:1689144024
Name:LILLY, KACEY LAUREN
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:LAUREN
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CHILVERTON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1145
Mailing Address - Country:US
Mailing Address - Phone:831-325-1292
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2308
Practice Address - Country:US
Practice Address - Phone:650-243-9089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst